Foreign Worker Hospitalization And Surgical Scheme Proposal Form (SKHPPA)

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1 Foreign Worker Hospitalization And Surgical Scheme Proposal Form (SKHPPA) Zurich General Insurance Malaysia Berhad is licensed under the Financial Services Act 2013 and regulated by Bank Nagara Malaysia. Non-Consumer Insurance Contracy Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for the purpose of providing medical insurance benefits to your employees, you have a duty disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance into, varied or renewed with us. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form (or when applied for this insurance) is inaccurate or has changed. You should ensure that this Proposal Form is completed correctly as it forms the basis of the insurance contract. The basis of contract clause shall not apply if You are an individual applying for this insurance. This Proposal Form shall part of the Policy contract. Policy owners are advised to read the policy carefully and understand its contents. You are encouraged to seek clarification from the Company if necessary. GOODS AND SERVICES TAX ( GST ) Important Notice Please be informed that the Goods and Services Tax ( GST ) will be implemented by the Government of Malaysia with effect from 1 April 2015 at a rate of six (6) per centum. Zurich General Insurance Malaysia Berhad reserves the right to collect from you an amount equivalent to the GST payable on the applicable premium for the policy period, or in the event that the policy period commences before but expires after 1 April 2015, to collect from you an amount equivalent to the GST payable on the applicable premium calculated from 1 April 2015 on a pro-rated basis. Your obligation to pay GST shall form part of the Terms and Conditions in your insurance policy. EMPLOYER'S PARTICULARS Business Registration No. /NRIC Name of Proposer / Employer Address of Employer Postcode Telephone No (Office) GST Registration No. Business/Occupation State (Mobile) GST Registration Date Manufacturing Plantation Servicing Construction Agriculture Maids 2118/6/P/G/S/M

2 PERIOD OF INSURANCE COVERAGE i) Period of Coverage Months ii) Insurer Status New Business Under SKHPPA scheme (First-Timer) Renewal with existing insurer New Business but Take-Over from other Insurer Date of Coverage: From To No. of worker(s) to be insured (if more than one (1) worker, please complete the Workers Particulars Form) PLACE OF EMPLOYMENT To be filled up only if Place of Employment Address is not the same as the Address of Employer above : a) Business Registration No./NRIC/ Passport / Construction Site No. / Project Reference No b) Place of Employment Address FOREIGN WORKER'S PARTICULARS (If application is for only one (1) worker, please complete the following particular) :- Name of Worker Nationality Passport No Date of Birth (DD/MM/YY) Gender Male Female Marital Status Single Married Divorced Widower Work Permit No. Work permit Expiry Date Nature of Work Who will be paying the premium for this insurance policy? Employer Foreign Worker Themselves Additional We may ask you additional questions if required. The questions on this proposal form and any other details we specifically request relate to facts which we consider material to underwriting this insurance. However, because no list of questions can be exhaustive, please consider whether there is any other material information which is known to you which could influence our assessment and acceptance of the risk. DECLARATION I/We understand that it is my/our duty to take reasonale care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to process my/our personal data revealed hereto. You are at liberty to process the data and share the information revealed thereto with any of your service providers and your other related companies provided that the revelation of my/ our personal data strictly for the purposes in relation to the insurance which I/we have applied hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act 2010 Date Signature of Proposer/Company Rubber Stamp

3 DETAILS OF PAYMENT Annual Premium Total Premium Goods and Services Tax (GST) Stamp Duty TOTAL RM (per worker) RM RM RM RM FOR OFFICE USE ONLY Enclose herewith payment Cash / Cheque No Amounting to RM Date/Time Received All Cheque must be made payable to Zurich General Insurance Malaysia Berhad Signature DESCRIPTION OF BENEFITS /COVERAGE HOSPITAL & SURGICAL BENEFITS 1) 2) 3) 4) 5) 6) 7) 8) a) Daily Hospital Room & Board (Maximum up to thirty (30) days) b) Intensive Care Unit [ICU] (Maximum up to fifteen (15) days Hospital Supplies and Services Operating Theatre Surgical Fees (Exclude organ transplantation) Anesthetist's Fees In-Hospital Physician Visits (Maximum up to thirty (30) days) In-Hospital Specialist Consultation Visits (Maximum up to thirty (30) days) Ambulance Fees/Medical Report Fees MAXIMUM OVERALL ANNUAL LIMIT (Items 1 to 8) As charged in accordance to charges consistent with Third (3rd) Class Room and Board to a maximum of RM per day in a Non-Corporatised Malaysian Government Hospital in conformance to the charges specified under Fees Act 1951, Fees (Medical) (Cost of Services) Order 2014 and/or its subsequent amendments. RM 20, ANNUAL PREMIUM (Before 6% Goods and Services Tax (GST) and RM10.00 Stamp Duty) RM (Per Worker) Important Note : All benefits payable for any number of disabilities in any one given period of insurance is subject to Overall Annual Limit of RM20, per Insured Person.

4 FOREIGN WORKER'S PARTICULARS FORM LIST OF WORKERS TO BE COVERED UNDER SKHPPA Name of Proposer / Employer Business Registration No./ NRIC /Passport Item No. Name of worker Nationality Passport No. Date of Birth (*Gender) **Marital Status Work Permit No Work Permit Expiry date Nature of Work Reference: *Gender: (L) Male; (P) Female **Marital Status

5 Verification of Proposer s Identification To be completed by Insurance Agents, Insurance Brokers or Staff of Insurance Companies relating to the Anti-Money Laundering & Anti-Terrorism Financing Act ANTI-MONEY LAUNDERING AND ANTI-TERRORISM FINANCING ACT 2001 (VERIFICATION OF PROPOSER S IDENTIFICATION) Name of Proposer Business Registration No. /NRIC No. In compliance with Section 16(2) of the Anti-Money Laundering And Anti-Terrorism Financing Act 2001, I hereby certify that the Proposer s original New NRIC No./Business Registration Certificate was verified and authenticated by me at the point of sales. Third Party Verification Signature of Insurance Agents, Insurance Brokers or Staff of Insurance Companies Name Date New NRIC No. Note: A copy of the Proposer s New NRIC/Business Registration Certification must be submitted together with this proposal if the Premium exceeds RM50,000

6 Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre:

7 Borang Cadangan Skim Kemasukan Hospital & Pembedahan Pekerja Asing (SKHPPA) Zurich General Insurance Malaysia Berhad adalah dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawal oleh Bank Negara Malaysia. Kontrak Insurance Komersial Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini untuk memberi manfaat insurans perubatan kepada pekerja, anda berkewajipan untuk mendedahkan apa-apa perkara yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang munasabah yang boleh dijangka, jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan ganti rugi, perubahan terma atau penamatan kontrak insurans anda. Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami (atau semasa permohanan insurans ini), apa-apa maklumat yang dinyatakan dalam Borang Cadangan tidak tepat atau sudah berubah. Anda harus memastikan bahawa Borang Cadangan diisi dengan tepat sebab borang tersebut membentuk asas kontrak insurans. Klausa asas kontrak ini adalah tidak terpakai jika anda adalah individu yang memohon insurans ini. Borang Cadangan ini hendaklah menjadi sebahagian daripada kontrak Polisi. Pemegang Polisi dinasihatkan untuk membaca polisi dengan teliti dan memahami kandungannya. Anda digalakkan untuk mendapat penjelasan daripada Syarikat jika perlu. Liabiliti Syarikat hanya akan bermula setelah pihak Syarikat memberitahu bahawa Borang Cadangan telah diterima ataupun Polisi telah dikeluarkan. CUKAI BARANGAN DAN PERKHIDMATAN ( GST ) Notis Mustahak Dimaklumkan bahawa Cukai Barangan dan Perkhidmatan ( GST ) telah dikuatkuasakan oleh Kerajaan Malaysia pada 1 April 2015 pada kadar enam (6) peratus. Zurich General Insurance Malaysia Berhad berhak memungut sejumlah amaun GST yang berpatutan keatas premium yang ditetapkan semasa tempoh polisi, atau sekiranya tempoh polisi bermula sebelum dan berakhir selepas 1 April 2015, memungut daripada pemegang polisi amaun GST keatas premium yang dikira secara pro-rata mulai 1 April Kewajipan pembayaran GST adalah membentuk sebahagian daripada terma dan syarat polisi insurans anda. BUTIR-BUTIR MAJIKAN No. Pendaftaran Syarikat Nama Pencadang / Majikan Alamat Majikan Poskod Negeri No. Telefon (Pejabat) (Bimbit) No. Pendaftaran Cukai Barangan dan Perkhidmatan (GST) Tarikh Pendaftaran Cukai Barangan dan Perkhidmatan (GST) Perniagaan/Pekerjaan Perkilangan Perladangan Perkhidmatan Pembinaan Pertanian Pembantu Rumah 2118/6/P/G/S/M

8 TEMPOH PERLINDUNGAN INSURANS i) Tempoh Perlindungan Bulan ii) Tarikh Perlindungan: Dari Hingga Bilangan pekerja yang akan diinsurankan (jika lebih dari seorang (1) pekerja, sila lengkapkan Borang Butir-Butir Pekerja yang disertakan dalam lampiran ini) Sektor (sila tanda) Construction (Pembinaan) Plantation/Agriculture (Perladangan/Pertanian) Wholesale/Retail Trade (Borongan/Runcit Perdagangan) Transport/Storage/Communication (Pengangkutan/Gudang/Perhubungan) Manufacturing (Perkilangan) Mining/Quarrying (Perlombongan/Quari) Services (Perkhidmatan) Others, please specify (Lain-lain, sila memperinci) TEMPAT PEKERJAAN Hanya perlu diisi sekiranya Alamat Tempat Pekerjaan berlainan dengan Alamat Majikan di atas : a) No. Pendaftaran Syarikat / KP / Pasport / Rujukan Tapak Pembinaan / Rujukan Projek b) Alamat Tempat Pekerjaan BUTIR-BUTIR PEKERJA ASING (jika permohonan untuk seorang (1) pekerja, sila lengkapkan butir-butir berikut) :- Nama Pekerja Warganegara No. Pasport Tarikh Lahir (HH/BB/TT) Jantina Lelaki Perempuan Taraf Perkahwinan Bujang Kahwin Bercerai Janda/Duda No. Permit Kerja Tarikh Luput Permit Kerja Jenis Pekerja Siapakah yang akan membayar premium untuk polisi insurans ini? Majikan Pekerja Asing Sendiri Tambahan Kami mungkin akan bertanyakan beberapa soalan tambahan jika perlu. Soalan-soalan pada borang cadangan dan lain-lain butiran yang diminta secara khusus berkait dengan fakta-fakta yang dianggap penting oleh pihak kami untuk proses pengunderaitan insurans ini. Walau bagaimanapun, disebabkan tiada senarai soalan-soalan yang lengkap, sila pertimbangkan sama ada terdapat apa-apa maklumat penting yang anda ketahui yang dapat mempengaruhi penilaian dan penerimaan risiko. PENGISYTIHARAN Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa menjawab soalan-soalan dalam borang cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan sepenuhnya dan dengan tepat soalan di atas. Saya/Kami dengan ini memberikan kebenaran tanpa syarat dan tanpa keraguan kepada pihak syarikat dan syarikat-syarikat bersekutunya untuk memproses data peribadi saya/kami yang didedahkan di sini. Pihak syarikat adalah berkebebasan untuk memproses data berkenaan dan berkongsi maklumat yang didedahkan di sini kepada mana-mana penyedia perkhidmatan dan mana-mana syarikat bersekutunya dengan syarat bahawa pendedahan maklumat peribadi berkenaan adalah bertujuan dan berkaitan dengan insurans yang saya/kami pohon di sini. Kebenaran ini diberikan selaras dengan peruntukan di bawah Akta Perlindungan Data Peribadi 2010 Tarikh Tandatangan Pencadang/ Cop Syarikat

9 BUTIR-BUTIR BAYARAN Premium Tahunan Jumlah Premium Cukai Barangan dan Perkhidmatan (GST) Duti Setem JUMLAH RM (setiap pekerja) RM RM RM RM UNTUK KEGUNAAN PEJABAT SAHAJA Bersama ini disertakan bayaran Tunai / Cek No Berjumlah Tarikh/Masa Diterima Tandatangan Semua Cek hendaklah dibayar atas nama Zurich General Insurance Malaysia Berhad KETERANGAN FAEDAH / PERLINDUNGAN MANFAAT KEMASUKAN KE HOSPITAL & PEMBEDAHAN 1) 2) 3) a) Bilik Hospital & Makan Harian (Maksimum sehingga tiga puluh (30) hari) b) Unit Rawatan Rapi (Maksimum sehingga lima belas (15) hari Bekalan dan Khidmat Hospital Bilik Bedah Bayaran Pembedahan (Tidak termasuk pemindahan organ) 4) 5) Bayaran Pakar Bius 6) Lawatan Pakar Perubatan Dalam Hospital (Maksimum sehingga tiga puluh (30) hari) 7) Lawatan Rundingan Pakar Dalam Hospital (Maksimum sehingga tiga puluh (30) hari) 8) Bayaran Ambulans/Bayaran Laporan Perubatan HAD MAKSIMUM TAHUNAN KESELURUHAN (Perkara 1 hingga 8) Bayaran yang dikenakan-mengikut bayaran yang selaras dengan Bilik & Makan Kelas Ketiga (ke-3) sehingga Maksimum RM160 sehari di Hospital Kerajaan Malaysia Bukan Korporat Mengikut Akta Fi 1951, Perintah Fi (Perubatan)(Kos Perkhidmatan) 2014 Dan/atau pindaan berikutnya RM 20, PREMIUM TAHUNAN (Sebelum 6% Cukai Barangan dan Perkhidmatan (GST) dan RM10.00 Duti Setem) RM (Setiap Pekerja ) Nota Penting : Semua manfaat berbayar bagi apa-apa bilangan hilang upaya dalam mana-mana satu tempoh insurans adalah tertakluk kepada Had Tahunan Keseluruhan sebanyak RM 20, bagi setiap Orang Yang Diinsuranskan.

10 BORANG BUTIR-BUTIR PEKERJA ASING SENARAI NAMA PEKERJA YANG DILINDUNGI Dl BAWAH SKHPPA Nama Pencadang / Majikan Pendaftaran Syarikat / KP / Pasport Bil No. Nama Pekerja Warganegara No. Pasport Tarikh Lahir (*Jantina) **Taraf Perkahwinan No pemit Kerja Tarik Luput Permit Kerja Jenis Pekerja Rujukan: * Jantina: (L) Lelaki; (P) Perempuan **Taraf Perkahwinan

11 Pengesahan Identiti Pencadang Insurans Untuk dilengkapkan oleh Ejen Insurans, Broker Insurans atau Kakitangan Syarikat Insurans berkaitan dengan Akta Pencegahan Pengubahan Wang Haram dan Pencegahan Pembiayaan Keganasan AKTA PENCEGAHAN PENGUBAHAN WANG HARAM DAN PENCEGAHAN PEMBIAYAAN KEGANASAN 2001 (PENGESAHAN IDENTITI PENCADANG INSURANS) Nama Pencadang Insurans No. Kad Pengenalan Baru/No. Pendaftaran Perniagaan Selaras dengan pematuhan Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram dan Pencegahan Pembiayaan Keganasan 2001, Saya, dengan ini mengesahkan bahawa Nombor Kad Pengenalan Baru/Sijil Pendaftaran Perniagaan asal pencadang telah disahkan ketulenannya ketika urusniaga dijalankan. Pengesahan Pihak Ketiga Tandatangan Ejen Insurans, Broker Insurans atau Kakitangan Syarikat Insurans Nama Tarikh No. Kad Pengenalan Baru Nota: Salinan Kad Pengenalan Baru/Sijil Pendaftaran Perniagaan Pencadang hendaklah disertakan bersama-sama dengan borang cadangan ini sekiranya bayaran Premium melebihi RM50,000

12 Zurich General Insurance Malaysia Berhad ( V) Tingkat 11, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Faks: Pusat Panggilan:

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